Uninsured patients in US (mostly) no longer pay crazed "list price" for hospital care

I had no idea this situation had improved — and I follow health care fairly closely ….

The Pricing Of U.S. Hospital Services: Chaos Behind A Veil Of Secrecy Uwe Reinhardt

… Until recently, only uninsured, self-paying U.S. patients have been billed the full charges listed in hospitals’ inflated charge masters, usually on the argument that the Medicare rules required it.21 This is how even uninsured middle-class U.S. patients could find themselves paying off over many years a hospital bill of, say, $30,000 for a procedure that Medicaid would have reimbursed at only $6,000 and commercial insurers somewhere in between.22

Because uninsured patients often are members of low-income families, many of them ultimately paid only a fraction of the vastly inflated charges they were originally billed by the hospital, but only after intensive and morally troubling collection efforts by the hospital.23 After a series of searing exposes of these collection efforts in the press—notably by staff reporter Lucette Lagnado of the Wall Street Journal—Congress held hearings on these practices.24 Partly under pressure from consumers and lawmakers and partly on their own volition, many hospitals now have means-tested discounts off their charge masters for uninsured patients, which bring the prices charged the uninsured closer to those paid by commercial insurers or even below.25 Some very poor patients, of course, have received hospital care free of charge all along, on a purely charitable basis…

The whole article is essential reading for journalists and anyone working in health care policy or as a healthcare executive. Hell, I didn’t know California mandated publication of hospital charge masters. Progress really is being made.

Reinhardt, by the way, is 80 years old. Long may he write.

All those "Democrats and white middle class" articles explained in four lines.

I’m going to translate the subtexts and signals of What’s Wrong With the Democrats? - The Atlantic into plain language:

1. Democrats should have disowned Black Livers Matter.
2. Democrats shouldn’t run a woman for the presidency.
3. Democrats should have lied more.
4. Democrats should have paid more attention to the economic collapse of the non-college (peak human, mass disability)

I agree with the fourth. I was worried about that before Trump took over. I don’t agree with #3, I think lying works a lot better on the GOP base than the Dem base.

Number one and two remind me of the Al Gore’s choice to embrace gun management measures. It was a progressive and brave act, but Americans showed they didn’t want it. Dems have not pushed it since.

I don’t think we’ll see a woman running for the presidency of the United States in the next ten years. Maybe 20 years. I was shocked that almost half of white college educated women voted for Trump. HRC was less excellent than Obama, but she was pretty good. Since white men are  hopeless the lack of support from white women was a killer.

I also think Dems will shy away from BLM like movements - at least for another decade. We won’t say that loudly, but watch what happens. American racism is stronger than many thought.

The are sad predictions. I hope I’m wrong, but I don’t have a lot of faith in post-Trump America. 

Now that we’ve got that out of the way, can journalists top writing these articles?

Escape from the Wheel of Time

I finished ‘A Memory of Light’. And the thirteen Wheel of Time volumes before that. I feel like I’ve been released from Compulsion.

It’s not high art. Some of it was a slog and not every thread was accounted for. The twists and retcons reminded me of long run comic book sagas. It can entertain though. Jordan turned a single volume book into a trilogy and then into a monster — and he more or less held it together. That’s worthy of a prize, or, in his case, a fortune.

Jordan died after book 11 and Brandon Sanderson wrote books 12-14 from notes and imagination. I thought there were some odd word choices in his first chapters, but either he settled in or I got used to his style. It was fun that three of the heroic characters were writers; I don’t think any villains were.

Game of Thrones, which I abandoned after a particularly misogynistic volume, is clearly an heir to WOT. I read that there will be a WOT inspired TV series — that will require a bit of editing.

I can’t exactly recommend WOT, but if you get sucked in the ride isn’t all bad. Most libraries will have it and there are many used volumes floating around, so you don’t have to buy every volume new. I bought about 5 and borrowed the rest from a friend and the library.

United airlines passenger assault: Blame the Feds.

Involuntary bumped seat leading to assault on a United Airlines passenger?

Blame the Department of Transportation (emphases mine):

If you’re involuntarily denied boarding, the Department of Transportation regulates what you’re entitled to. Here are the rules, as published by the DOT …

… If the substitute transportation is scheduled to get you to your destination more than two hours later (four hours internationally), or if the airline does not make any substitute travel arrangements for you, the compensation doubles (400% of your one-way fare, $1350 maximum)….

The US government sets the maximum compensation amount. I suspect that amount was set years ago and hasn’t changed

The article I found this in calls $1,350 “sizable”. No. That is not “sizable". I was almost bumped myself because Delta couldn’t find takers of a similar offer. $1,350 was a reasonable offer in 1990. In our 2017 lives a reasonable offer starts at $5,000. If there has to be a  limit that limit should be around $10,000 — regardless of ticket price.

So, yeah, I hate United as much as most travelers. But this one the Feds own.

Broken world: applying for a minimum wage job via a corporate HR web site

My #1 son is a special needs adult. He’s excited to start at $10/hour job running food around a sports stadium. It’s work he can do — he’s got a great sense of direction and he is reasonably fit.

The job engagement process is run by an archaic corporate web site that looks like it was built for IE 3. The site claims to support Safari but warns against Chrome. It is not useable on a smartphone.

The HR process requires managing user credentials, navigating a complex 1990s style user interface, and working around errors made by the HR staff — who probably also struggle with the software. He would not have the proverbial snowball’s chance without my ability to assume his digital identity.

Sure, #1 is below the 5th percentile on standard cognition tests — but this would have been a challenge to the 15th percentile back in the 90s. In the modern era, where most non-college young people are primarily familiar with smartphones, this is a challenge to the 30th percentile.

Which means the people might want to do this job are being shut out by the HR software created to support the job. Which probably has something to do with this.

The world is broken.

#massdisability

All our family healthcare visits are now billed as CPT E&M Code "Level Four"

Very few people will understand what that subject line means.

The short version is that the way we account for physician services was born broken in 1994 and it is now in a state of advanced collapse.

It can’t go on and it can’t stop.

Don Berwick, the best CMS administrator we’ve ever had (forced out by GOP) said this five years ago:

.. Dr. Donald Berwick, the immediate past administrator of the Centers for Medicare and Medicaid Services (CMS), which administers the Medicare program, said a small portion of the billing increase is likely caused by outright fraud, but in the majority of cases hospitals are legally boosting profits by targeting the vulnerabilities of Medicare’s payment system. “They are learning how to play the game,” Berwick said about the hospitals....

... Berwick, the former CMS head, said patients haven’t changed. What’s changed is the aggressiveness of how hospitals bill. “They are smart,” Berwick said. “If you create a payment system in which there is a premium for increasing the number of things you do or the recording of what you do, well, that’s what you’ll get.”...

See also

• Gordon's Notes: Health care reform. Be humble. Be afraid of the accounting rules. 1/2009. RBRVS. We had such good intentions.
• Gordon’s Notes: Electronic health records and payment increases: It’s not fraud. 10/2012. 

Curious Priceline credit card fraud today

Around 2:30pm Amex.app tells me a $1.00 authorization charge has been placed for Priceline. Which I didn’t do. 

I’m in a meeting so I figure I’ll follow up later.

Around 4pm I get a Google Voice transcription from “Cynthia” of the “Priceline.com fraud prevention department” asking me to call 203-441-8455. Someone has ordered two plane tickets on my Amex card.

I call Amex and they do see the transactions. They never made it to my account though, so they must have run hard into Amex fraud detection (best in the industry AFAIK). I’m issued a new card. Noteworthy: I’m told my many recurring online transactions won’t break and later in the day Apple Pay tells me it’s automatically updated my information with the new card — though I won’t get the physical card for a few days.

I do call 203-441-8455. They claim to be Priceline Fraud Prevention, but they sound awfully shady. I already knew I wasn’t going to give them any personal data so I carried on. (I later googled the number, found a 2012 ref that said this was indeed them.)

I was told two plane tickets were bought on my card — and there’s a name attached to each ticket (vaguely Indian/middle eastern sounding names). The harried woman says the plane leaves in 30 minutes so they probably can’t block them. Which is, of course, Priceline’s problem. There’s a reason I like American Express.

Note to Priceline.com: your Fraud Prevention department should sound less like an international call shop scam operation.

I checked my ancient and little used Priceline account. It had a robust password, had no transaction records, and it didn’t hold my Google Voice number. I don’t think it was hacked. I changed the password anyway.

It’s a bit weird. Why would someone use a stolen credit card to buy plane tickets when they have to match the name on the tickets to their personal ID? It seems a risky behavior! And how did Priceline get my Google Voice number? (Maybe from AMEX?) Least odd is that someone stole my AMEX credentials (the physical card is at home). I assume all my credit card numbers are available online for a few dollars.

I wonder if Priceline is a particularly effective way to buy plane tickets with a stolen credit card number? I doubt Priceline will report any of this to the police, even though they probably have the traveler’s true names.

A change to my publishing streams

These are the last days of app.net. It ends in 3 days. App.net has been good to me. Great tools, smart and interesting people, RSS integration (albeit grudgingly at first) and the best communication/conversation platform I’ve worked with. App.net was what Twitter should have been. It has made clear how badly Twitter has failed.

These are, surprisingly, also the end times for Maciej’s Pinboard as a publishing platform. I have 33,236 pins there, and something is broken. Neither pinner.app or pushpin.app are able to connect and download the streams. From what Maciej has written in the past I may have passed some throttling limit. I’m using Pinboard in ways he did not intend — and the iOS apps don’t scale either. 

So I need to make some changes. Gordon’s Notes and Tech will stay on Blogger for now — it’s been surprisingly robust and trouble free for many years. It helps that there’s an exit strategy to WordPress if Google kills it, but as best I can tell Google is going to keep Blogger limping along.

My DreamHost wordpress microblog has mirrored my pinboard stream for years. I’m going to see if there’s a way to make it a true microblog publishing platform. I’m not sure how to do that, in particular it’s not obvious how I can conveniently post via Reeder.app. It will take me a while to work that out.

In the meantime there are several app.net spinoffs in the work. I’m tracking several of these as much as my time allows - especially pnut.io (@jgordon) and 10centuries (@jgordon). March 2017 is a heck of a month for me so things have gone slowly.

Uncertain times! For now if you follow kateva.org/sh you’ll see what I’m up to, no matter how the process evolves.

Warfare goes to the elite

Once upon a time tens of thousands of New Yorkers moved paper from one file cabinet to another. Once upon a time there were jobs for strong bodies. Once upon a time you could be blue collar and middle class.

Once upon a time anyone could be a warrior …

Special Operations Troops Top Casualty List as U.S. Relies More on Elite Forces

… “We’ve moved out of the major combat operations business,” said Linda Robinson, a counterterrorism expert at the RAND Corporation. In recent years, she said, the military has effectively outsourced rank-and-file infantry duties to local forces in places like Afghanistan, Iraq and Syria, leaving only a cadre of highly skilled Americans to train troops and take out high-value targets…

Now the physical and cognitive elite dominate warfare. Automation and globalization — in this case drones and outsourcing to local infantry.

Trump didn’t come from nowhere.

Crisis-T: what to do about the delusions and the lies.

I’ve been using “crisis-T” as a tag for our times. I used to think it was a bit melodramatic; that maybe T would somehow veer to the fantasies of Thiel and the like.

Welcome to week two of Crisis-T. A week in which I’ve started monitoring neo-soviet propaganda for clues to what Bannon, Flynn and Putin are thinking (the troika).

Emily and I are still working out how to respond to this. I hope the March for Science happens — I’d join that one way or another. We already subscribe to the NYT, The Atlantic, The New Yorker, and Talking Points — it’s essential to support journalism with hard coin. The 2018 congressional campaign has begun and we will be active (I’ll likely vote in the GOP primaries, more on that later). We’ve done our first of many ACLU and Planned Parenthood donations. Basically we more or less track what Scalzi is doing.

I write and tweet of course, but that’s more therapeutic than useful. It does mean though that I run into some of the issues that real journalists face. Like how to approach the maelstrom of lies and delusions that Bannon and Trump produce. On the one hand presidential speech is a form of action, it can’t be disregarded. On the other hand I’m beginning to worry Bannon is not a conventional idiot. He may have a real talent for strategic propaganda and effective distraction.

I wonder if we should treat the lie-stream like the weather.  Box it on the proverbial page 2 as Bannon-T lies and delusions of the day. Each lie-delusion is then listed with a contrasting statement of testable reality. Then the main pages can focus on even more important problems, like swapping the Joint Chiefs of Staff and Director of National Intelligence for Bannon on the principals committee of the National Security Council.

More as we figure this out …

Update Jan 30, 2017: Jeff Atwood has one of the best action lists I’ve seen.

Crisis-T: Subscribing to the NYT (and a few others)

The absolute minimal response to Crisis-T starts with financial support for quality journalism and donation to the ACLU. If you have a reasonable income and don’t do some of this then you aren’t even trying.

Today quality mainstream journalism means the New York Times and perhaps the Washington Post. The Economist might an option if you’re a conservative, but they don’t do much investigative journalism. Really, if you’re a conservative who opposes T then WaPo and the NYT are your options. (The WSJ is not an option.)

Outside of the mainstream I’m a fan and supporter of Talking Points Memo ($50/y). It’s avowedly liberal-dem but also conscientious journalism. Josh Marshall is a marvel. The New Yorker’s been doing great work, we support them as well.

Of these minimal responses the NYT is the most expensive. At one point their list subscriber price was somewhere north of $350 — though list was mostly for those who didn’t shop around. I still have a faculty price of $98/year for web and app access though I haven’t taught for years. It’s possible all you need to qualify is a .edu email.

Today the web/app price list price is $143. I’d pay that much, but you can do a yearly subscription through the iTunes app for $130. I couldn’t find the Android and Kindle subscription costs.

The best price is the student price - at $52 a year billed monthly.  Some schools may pay for digital access to all students, but if you opt into a school-funded free subscription you’re not supporting journalism. I don’t think the NYT does anything to block limited sharing of a student account. It appears the only test for the student rate is an educational address

I suspect I’m not the only subscriber who shares their account with a spouse. That’s a substantial, if improper, discount. (“Subscribers to All Digital Access at the college rate are not eligible to share their access with a family member.” — which implies other subscribers can share.)

So you have a wide range of ways to pay for digital access to the NYT - from list at $143/y to iTunes at $130/y to student/.edu at $52/y. Spousal sharing reduces the cost even more. Some rates are more proper than others, but all support investigative journalism. Pick one.

PS. Dear NYT: $100 a year with spousal sharing would be a great way to grow your readership.

CrossFit has invaded my dreams. You should try it.

I awoke last night sweaty and anxious.

I was dreaming about the kipping muscle up; a move that still eludes me.

Which is nuts. I am an old man. Acrobats do this stuff in their sleep. Even when I was young I didn’t aspire to being an acrobat. CrossFit is invading my dreams…

Maybe it’s because the regular workouts have become normal. I was 53 when I started 3.5 years ago, now after a few hundred workouts even handstand pushups don’t seem that exceptional. After the first year I did 70-80% of the “women’s Rx”. Now as an older guy I sometimes do the “men’s rx” — and I usually do at least the women’s. I started out going twice a week, now I do 3-4 CrossFit workouts and 2 light workouts at a typical gym while my 17yo does his Tae Kwon Do. (Plus hockey, mountain biking, inline skating, etc)

It’s hard to remember when tattoos and workout music seemed novel or when I thought big guys would notice how puny I am (that’s truly funny, but there you go).

I once thought it was kind of amazing to do CrossFit as an old man. Now it seems like something anyone with decent knees can do. It’s just a matter of scaling. Do 1/5 of the weight and half the reps. Do regular pushups instead of handstand pushups. Use bands. It can mostly be scaled. It’s hard to get around truly bad knees though.

So what sticks now are the things I suck at, skill moves like double-unders (I’m absolutely the world’s worst) and the muscle ups (bar and ring).

CrossFit is fun. It’s safer than walking around Saint Paul — our drivers are distracted dolts. Good gyms like Union Fitness - CrossFit Saint Paul will make you feel your money is well spent. Lots of slots for a flexible schedule, great peers, great coaches. Done with care CrossFit will fix your sore back (once mine was worse than yours). Exercise doesn’t control weight in clinical trials — but they’re not sending people to CrossFit. CrossFit will control weight if you have any kind of diet control. You don’t have to move to the Twin Cities (though you are welcome) either, there are good gyms in small towns and big cities now. You can find one near you.

Give it a try.

If my familial genetic arthritis holds off (big if) I now don’t see why I can’t be doing CrossFit into my 60s and 70s. Sure I won’t lift as much, and maybe I’ll never do a muscle up, but I’m good at scale. CrossFit ain’t the fountain of youth, but it’s as close as we can get.

Quicken for Mac 2017 -- $45 upgrade for nothing.

Quicken for Mac 2017 new features …

Compare your income and spending year over year with custom reports
Customize your budgeting goals month-by-month (12-month budget)
Pay your bills in Quicken with Quicken Bill Pay (fees apply)
Get more power on-the-go with the improved mobile app
Enjoy a new look that’s easier to use and navigate

On the other hand …

Quicken 2017 for Mac does not have certain investment reports/views, such as Performance (IRR), or Allocation by Investment.

We’ve been using 2015 and somehow I thought the 2017 update was worth paying for. Wrong. The only change I notice is new UI to learn.

That was a real waste of money. 

Intuit sold Quicken for Mac to a private equity company. The corporate headquarters are “3760 Haven Avenue, Menlo Park, CA 94025”. This is the current street view (7/2016).

We can live with Quicken 2015 - or 2017. We can do our investment allocation reports by hand. So I don’t think it’s a bad buy — once.

No upgrades though. Quicken 2017 is a classic, stinky, private equity move — fire everybody, put in a little bit of work, squeeze the market.

Stick with the version you have.

Crisis-T: blame it on the iPhone (too)

It’s a human thing. Something insane happens and we try to figure out “why now?”. We did a lot of that in the fall of 2001. Today I looked back at some of what I wrote then. It’s somewhat unhinged — most of us were a bit nuts then. Most of what I wrote is best forgotten, but I still have a soft spot for this Nov 2001 diagram …

I think some of it works for Nov 2016 too, particularly the belief/fact breakdown, the relative poverty, the cultural dislocation, the response to modernity and changing roles of women, and the role of communication technology. Demographic pressure and environmental degradation aren’t factors in Crisis-T though.

More than those common factors I’ve blamed Crisis-T on automation and globalization reducing the demand for non-elite labor (aka “mass disability”). That doesn’t account for the Russian infowar and fake news factors though (“Meme belief=facts” and “communications tech” in my old diagram). Why were they so apparently influential? 

Maybe we should blame the iPhone …

Why Trolls Won in 2016 Bryan Mengus, Gizmodo

… Edgar Welch, armed with multiple weapons, entered a DC pizzeria and fired, seeking to “investigate” the pizza gate conspiracy—the debunked theory that John Podesta and Hillary Clinton are the architects of a child sex-trafficking ring covertly headquartered in the nonexistent basement of the restaurant Comet Ping Pong. Egged on by conspiracy videos hosted on YouTube, and disinformation posted broadly across internet communities and social networks, Welch made the 350-mile drive filled with righteous purpose. A brief interview with the New York Times revealed that the shooter had only recently had internet installed in his home….

…. the earliest public incarnation of the internet—USENET—was populated mostly by academia. It also had little to no moderation. Each September, new college students would get easy access to the network, leading to an uptick in low-value posts which would taper off as the newbies got a sense for the culture of USENET’s various newsgroups. 1993 is immortalized as the Eternal September when AOL began to offer USENET to a flood of brand-new internet users, and overwhelmed by those who could finally afford access, that original USENET culture never bounced back.

Similarly, when Facebook was first founded in 2004, it was only available to Harvard students … The trend has remained fairly consistent: the wealthy, urban, and highly-educated are the first to benefit from and use new technologies while the poor, rural, and less educated lag behind. That margin has shrunk drastically since 2004, as cheaper computers and broadband access became attainable for most Americans.

…  the vast majority of internet users today do not come from the elite set. According to Pew Research, 63 percent of adults in the US used the internet in 2004. By 2015 that number had skyrocketed to 84 percent. Among the study’s conclusions were that, “the most pronounced growth has come among those in lower-income households and those with lower levels of educational attainment” …

… What we’re experiencing now is a huge influx of relatively new internet users—USENET’s Eternal September on an enormous scale—wrapped in political unrest.

“White Low-Income Non-College” (WLINC) and “non-elite” are politically correct [1] ways of speaking about the 40% of white Americans who have IQ scores below 100. It’s a population that was protected from net exposure until Apple introduced the first mass market computing device in June of 2007 — and Google and Facebook made mass market computing inexpensive and irresistible.

And so it has come to pass that in 2016 a population vulnerable to manipulation and yearning for the comfort of the mass movement has been dispossessed by technological change and empowered by the Facebook ad-funded manipulation engine.

So we can blame the iPhone too.

- fn -

[1] I think, for once, the term actually applies.

Investment things I learned in Crisis-T

All the money Trump will take from the poor and give to the rich has to go somewhere. So share prices should rise.

On the other hand, a 10% import tariff will lead to a global trade war. I’m particularly looking forward to the carbon tariffs an angry China applies to the US. So share prices should fall.

Corporate behemoths will increase monopoly and monopsony powers and fully leverage regulatory capture in an era where corruption exceeds living memory. So share prices should rise.

Trump will, WTF, resume underground nuclear testing or something like that. So share prices should fall…

Hey, I don’t know what the market is going to do. If I knew I’d hire people to manage the billions we don’t have. I do know the our equity investments have grown over the Obama years, I see some warning signs, and our portfolio is now equity-heavy. So it makes sense to rebalance. Crisis-T just means I made myself do it.

I chose to rebalance primarily in our retirement accounts, so the sales had no tax implications. I sold shares and parked the cash. In a few months, when we learn if the GOP Senate has a spine, we may sell more in our taxable accounts and shift the retirement back into equities. It’s probably not an orthodox way of proceeding, but it’s relatively easy to adjust.

Since I rarely mess with our investments (largely S&P, extended market, and whole market index funds — plus college 529 plans I don’t touch) I learned a few things. In no particular order …

1. If you sell shares in Vanguard’s ultra-cheap low overhead index funds you can’t buy back into the same fund until 30 days post-sale. So if you make it one big sale if the timing is good. Vanguard makes it easy to create a cash fund to hold sales within a particular account family.
2. Fidelity’s 401K accounts are completely different business from their HSA accounts which are unrelated to their … Oh. Heck. I don’t like Fidelity.
3. It takes a long time for these mutual fund orders to sell. They seem to sell at near market close the day after the order is placed — and the online accounts aren’t updated for a while. So you can’t do any of this under market pressure. I placed a sell order at 7pm on Thur, they were in process Friday, the web site was updated Sat pm.
4. If you’re not using a SEP IRA you might as well roll it into a regular IRA. You can always create a new SEP IRA in future.
5. Rollovers are complicated and slow. Even the Vanguard ‘concierge’ people seemed unsure about all the rules. You can borrow against 401K funds, but the investment options may be poor. You may be able to rollover a former employers 401K into a new employers 401K — but it’s all special cases. There may be a way to create an IRA account that a 401K can roll into and still be able to rollover into a 401K — but that’s just weird. Once you mix a 401K with IRA funds you can’t reverse it, it’s all IRA then. There’s a reason people spend money for tax lawyers.
6. Vanguard has a much better web site than Fidelity and Vanguard message responses are excellent.
7. Vanguard is in the midst of switching all their funds into a brokerage framework. I worry that it will increase costs but I’m naturally suspicious. I’d like to read something about why the change.